PSMA-PET: Documentation of Patient Eligibility and Reimbursement


Panelists discuss how they typically document prostate cancer patient eligibility when ordering PSMA-PET imaging, and share strategies to optimize insurance coverage and reimbursement.


David Albala, MD: Ashley, talk to me about the documentation. I’m a practicing urologist; what do I need to have in my notes to suggest that this test will be covered by insurances? In your experience, are there any buzzwords that are critical? You guys have ordered lots of these tests. I’m sure the audience is going to be a wide variety, from none to many. Are there any tips that you can give us to ensure that these studies will be covered by insurance? What do you recommend doing for the documentation?

Ashley Ross, MD, PhD: Quite frankly, it’s become easier in my area. I basically just say that the person has this NCCN [National Comprehensive Cancer Network] risk. I say they’re at risk of having metastatic disease, and we need to appropriately stage them. Where [there is] a biochemical recurrence, I say the PSA [prostate-specific antigen test] is above X. There’s no guideline about where you put it, for that. But I’ll say the PSA is above this. It’s a rising PSA after treatment, and I’m suspicious that there’s metastatic disease present. I want to get a PET PSMA [positron emission tomography-prostate-specific membrane antigen]. When I get a denial, or my office gets a denial, as these new technologies get out there, Gary mentioned that there’s representatives that help us onboard it, get the tracer there, help us with logistics. If you say, “Look, I just want to look at your verbiage. What do you guys do when you talk to them?,” they actually can help you with good summaries of the data. There are papers that, for example, Dr Andriole’s a major author on a lot of these papers with PET scanning. But you don’t want to have to write a huge letter each time, you want to draw from different sources. They often have that consolidated, and you can submit that. Obviously, we’re hoping for the day when all of them just get approved. I think that the reason it’s coming to that is the peers realize. Gerry mentioned earlier, he was alluding to some of the studies, like the EMPIRE-1 study, which used F18 fluciclovine. Then your treatment planning is better. While we don’t know if this going to affect overall survival or not, it certainly can affect the time of your curve of treatment and lessen costs. If you pick the right treatment strategy first, you probably get more quality-of-life years out of your patient and lessen the overall health care cost. I know that Dr Andriole’s had some denials. Gary, I’m not sure about your area, but I’ve seen the resistance going lower and lower and lower, so that I don’t have to write a bunch of, quite frankly, waste-of-time stuff and boiler plate in my note. I can just say, “This is what it is.” The insurance says, “Yup, this is better care.” I guess I’m blessed because in Gerry’s realm, which I used to be on the East Coast, they’re still putting a bunch of resistance to best care. One more soapboxing thing. I always see these things that are judging doctors, that are saying, “Well, this is your doctor metric. This is how your patient reviews were.” I’m still waiting for the day when we’re judging insurance companies. That this insurance company always denies guideline-approved standard of care. If you’re looking at Medicare Advantage plans, I’m sure that Gerry’s patient was not Medicare, but Medicare Advantage. These Medicare Advantage plans frequently refuse guideline-appropriate treatments and better options for your patients. I don’t know why we don’t have that yet, but I think that’s the next thing that I would like to soapbox for this small bit.

David Albala, MD: You think it’s almost like what we’ve seen with MRIs? Remember, when we first started doing MRI imaging, none of the insurance companies would approve it. Now it’s really the urologist. If you don’t write an MRI fusion biopsy, you’re not going to get one. But you don’t jump the hurdles that we’ve seen. We’ve come a long way with MRI, and I think we’re at the beginning stages of starting to see that progress through with this type of imaging. Gerry, what’s your thought?

Gerald Andriole, MD: I have very little to add to what Ashley said. I think it’s highly dependent on some arcane, local rules. It has varied a bit between St. Louis and the Baltimore-Washington metropolitan area.

Gary Ulaner, MD, PhD, FACNM: If I can go back to buzzwords. What do you want to put on your orders? A summary of what we’ve already said: newly-diagnosed, high-risk, those are good buzzwords for getting your PSMA PET scan approved. Prostate cancer, post-prostatectomy, or radiation therapy, and then use the term, biochemical recurrence, and give the PSA value. Those are good buzzwords. Then “patient is being evaluated for PSMA-targeted therapy.” I think those are buzzwords that, if you do get, then, a rejection, you can turn around and show them the SNMMI [Society of Nuclear Medicine and Molecular Imaging] appropriate use criteria and say, “You asked for these AUCs. Here’s the AUC that says that the PSMA PET scan is appropriate in this patient.”

David Albala, MD: That’s terrific.

Transcript edited for clarity.

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